Ibrahim A. Abdelazim (Abdelazim IA; IA Abdelazim) Professor of Obstetrics and Gynecology, Ain Shams University,, Egypt and Consultant of Obstetrics and Gynecology, Kuwait Working as Specialist in Ahmadi Hospital, KOC, Kuwait. Researcher ID: F-7566-2013 Sixty-two (62) published researches in the field of Obstetrics and Gynecology till now; 29 International Journals & 33 Local Journals.

Evaluation of Infertility Women INDICATION Indicated due to failure of conception after one year of regular unprotected intercourse. Indicated for women over 35 years, if she failed to conceive after 6 months of regular unprotected intercourse, because, the fertility decline when woman approach the age of 40 years.

Requirements of Woman Evaluation Before evaluation of infertile woman; the male partner should evaluated starting with semen analysis, and if the semen analysis of the male partner is within normal, evaluation of the female partner should started. Evaluation of the infertile woman should carried in cost-effective manner to identify the possible causes of infertility using the least invasive investigations.

Methods of evaluation of infertile woman History and examination. Documentation of ovulation and ovarian reserve. Evaluation of cervical causes of infertility. Evaluation of uterine causes of infertility. Documentation of the tubal patency. Exclusion of peritoneal causes of infertility.

1. History and Examination Infertility duration and previous treatment of infertility. Menstrual irregularities (PCOS and anovulation). History of contraception. Sexual history (frequency, dyspareunia and use of lubricants). Previous surgery (fibroid, ovarian cyst or appendectomy) Previous PID or STD. Family history of infertility problem Endocrine disorders (thyroid disease, galactorrhea, hirsutism). Exposure to environmental toxins.

Physical Examination Body mass index (BMI) Thyroid and Breast examinations Hair distribution (Hirsutism in PCOS) Vaginal, speculum and bimanual pelvic examination combined with TVS for evaluation of the vagina, cervix, uterus and Both ovaries.

2. Documentation of Ovulation Ovulatory disorders identified as possible cause of infertility are; PCOD, excess weight gain or loss, endocrine problems as thyroid problems and/or hyperprolactinemia. Methods of documentation of ovulation include: 1). Basal body temperature (BBT): Ovulatory cycles associated with biphasic BBT recordings, and an-ovulatory cycles associated with monophasic BBT pattern. BBT assay is not the best method for documentation of ovulation. 2). Endometrial biopsy and dating: Detection of secretory endometrial, resulting from the post-ovulatory progesterone effect was the gold standard method to diagnose ovulation and should be only considered for diagnosis of endometrial pathology as endometritis and malignancy.

3). Serum progesterone assay: is a reliable indicator of ovulation and luteal function. Serum progesterone should done 1 week before the beginning of the menses rather than Day-21 assay. Serum progesterone >3 ng/ml is reliable indicator of ovulation. Serum progesterone >10 ng/ml is reliable indicator of proper luteal function. 4). Luteinizing Hormone (LH) assay in urine: Using commercial ‘‘ovulation detection kits’’ to identify the LH peak occurring 1 or 2 days before the ovulation. Urinary LH kits is an accurate, easy and reliable method to identify the best ovulation and fertility time. 5). Trans-vaginal ultrasound (TVS): Can detect growth of the ovarian follicles and evidence of ovulation through; collapse of the mature follicles, and appearance of post-ovulatory clear fluid in the POD. 6). Endocrine assessment: TSH and Prolactin

Evaluation of the ovarian reserve Ovarian reserve describes the reproductive ability of the woman through identification of the number and quality of the oocytes available in her ovaries. Decreased ovarian reserve (DOR) means women whose response to external ovarian stimulation reduced compared to similar women of the same age. Ovarian reserve can detected by: Cycle-Day 3 FSH and estradiol levels, clomiphene citrate challenge test, antral follicle count (AFC), and anti-mullerian hormone (AMH).

Cycle Day-3 FSH >10–20 mIU/ml is associated with DOR. Estradiol (E2)<50-60 pg/ml with normal FSH in follicular phase associated with DOR. CCC test: Assessment of the FSH on Day-10 of the cycle after 100 mg CC daily from day 5-9 of the cycle. High serum FSH after clomid stimulation suggest DOR. AFC: The number of the follicles measuring 2–10 mm in diameter in the ovaries in the follicular phase by TVS. Mean AFC of 5.2±2 associated with DOR. AMH: Secreted by follicular granulosa cells, FSH-independent and can be measured in any day of the cycle. AMH <1 ng/ml associated with DOR.

3. Evaluation of cervical causes of infertility Evaluation of the cervical causes of infertility using post-coital test (PCT) which means microscopic examination of the cervical mucus specimen taken before the ovulation for the appearance of the motile sperms is not more recommended for routine evaluation of infertile women, because of the subjective nature of the PCT.

4. Evaluation of uterine causes of infertility using: Hysteroscopy is the gold standard for evaluation of the uterine cavity and for diagnosis of the intrauterine pathology. Imaging: TVS, 3D US and MRI to diagnose uterine fibroids, uterine polyps and congenital uterine anomalies. Hysterosalpingography (HSG) Used for diagnosis of uterine anomalies, endometrial polyps and sub-mucous fibroids with high PPV. Saline Infusion Sonograpohy (SIS) Means infusion of saline through the cervical canal during the TVS. SIS used for diagnosis of uterine anomalies, endometrial polyps and sub-mucous fibroids with >90% PPV.

5. Documentation of the tubal patency   Methods used to document tubal patency include; HSG and SIS. Diagnostic Laparoscopy with dye test used for the diagnosis of tubal occlusion or patency + peri-tubal adhesions which not diagnosed by HSG or SIS. Chlamydia trachomatis antibodies (CAT) detected in infertile women with tubal pathology with high NPV (90%).

6. Evaluation of peritoneal causes of infertility Laparoscopy is the most specific method used for the diagnosis of peritoneal factors of infertility. Laparoscopy indicated in infertile women with abnormal HSG or suspected peritoneal disease as endometriosis and not recommended as routine evaluation of infertility women.